HomeMy WebLinkAboutMiscellaneous - 49 ELMWOOD STREET 4/30/2018 49 ELMWOOD STREET
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MASSACHUSElTS MASSACHUSETTS
FIRE INCIDENT REPORT STATE FIRE MAHSHAL
i situation found I action taken 1 mutual aid I
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| fixed property | | ignition factor | |
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i correct address | zip co �s�� | census |
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| | occup. name last, first, mi | telephone | room or apt !
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| ( owner name last fir t i | address ���-----
, s , m a ress | telephone |
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| | method of alarm | | district | no. alarms !
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| | #fire service | #tankers | #engines � #aerial app 1 # other vehi-----|
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| hazardous material | substance | special equip used |
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| numbers of injuries | number of fatalities ( rescues f
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| mobile property | | vehicle stolen ? | estimated total dollar-1
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| insurance company | total insurance | claim paid |
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| | year | make | model
T-RAT-o-r F lic no | vin# � ���--------- |
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| | if equip involved | year | make | model | serial no -�-------|
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| complex ( | area of origin | equip inv in ��nition |
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| form of heat ignition material ignited | form | type | |
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| method of extinguishment | | level of fire origin
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} numbers of stories | | construction
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| extent of flame damage | | extent of smoke damage
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| detector performance | | sprinkler performance | /
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IAT smoke spread | material generating | form / | type
| beyond room | most smoke : | | @0 | 1 001
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R | weather conditions |
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| -------------------- } entries contained in this report are intended . |
| CLOUDY AND COOL | The sole use of the state fire marshal. Estimat- |
| TEMP 50 DEGREES | ions & evaluations made herin represent "MOST |
} | LIKELY" & "MOST PROBABLE" cause & effect . Any !
| | representation as to the conditions outside the |
| | State Fire Marshals Office is neither intended nor |
) member making report | implied |
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' rM. RINC4 INCIDENT REPORT NARRATIVE N1/N6/98 21 :31 PAGE 2
v5. 5d CASE#: 4692 SED: 01
E-1 HAD READINGS IN THE FIRST FLOOR BETWEEN 8PPM AND 13PPM
WHEN WE ENTERED THE BUILDING. WE CALLED FOR GAS COMPANY AND
VENTED THE BUILDING. WE CHECKED THE CELLAR AND UNTAIRS AND
HAD NU CO READINGS. THE FlRSC &lOUR HAD THE CO LEVELS. GAS
COMPANY CHECKED THE STOVE AND FOUND WAS NOT RUNNING PROPERLY,
OVEN WAS SHUT OFF AND GAS INSPECTOR WILL CHECK ON STOVE.
THE OWNER WAS INSTRUCTED TO HAVE STOVE SERVICED BY TECHNICIAN.
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CHECKLIST FOR CARBON MONOXIDE
Location of Incident: 4-61 4-)000 Date of incident
QUICK CHECKLIST OF OCCUPANTS /
Headache yes no V Fatigue yes no
Nausea yes no v- Dizziness yes no
Confusion yes no_
Are any members of the household feeling ill? yes no i,�
Do the residents feel better away from the house? yes no
Since the detector's alarm went off, what have you do e?
Shut- off carbon monoxide sources yes no
If yes which sources 6-0q--S
Let in fresh air? yes_LZ no
If yes how did you let the air in
How long did you let the air in /�J— --,s
PPM reading ambient outside the dwelling l)
Highest PPM reading in the dwelling _
Carbon monoxide detector present? yes no
Ifyes list the number of detetors locations and make, and serial number of each below.
I. 1-1 —'
2. /, L D
3. jj 7 0
4.
Which detector(s) by number above activated?
SOURCE CHECKLIST LOCATION PPM READING
Chimney clogged flue, blocked opening
Fireplace(s) Natural gas, LPG, Wood(indicate type for each fireplace)
Gas Appliance (if Gas Company on Scene they can perform this check)
(IF MORE THAN I OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL
ON THE COMMENTS PAGE WITH ITS LOCATION, AND PPM READING)
refrigerator
stove
vent over stove ' 10P,&7
clothes dryery
water heater
furnace
Oil burner
car garage 6
Entranceway from garage to house C�
Name of individual operating the.CO monitor .�'lQ✓ �
Person completing the Checklist